Healthcare Provider Details

I. General information

NPI: 1235377623
Provider Name (Legal Business Name): DIAMOND SPRINGS DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2009
Last Update Date: 10/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 MAIN STREET STE. 102 POST OFFICE BOX 500
DIAMOND SPRINGS CA
95619-0500
US

IV. Provider business mailing address

PO BOX 500 STE. 102
DIAMOND SPRINGS CA
95619-0500
US

V. Phone/Fax

Practice location:
  • Phone: 530-344-0290
  • Fax: 530-344-0291
Mailing address:
  • Phone: 530-344-0290
  • Fax: 530-344-0291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD43010
License Number StateCA

VIII. Authorized Official

Name: DR. MITCHELL A GOODIS
Title or Position: DENTIST
Credential: DDS
Phone: 530-344-0290